Palliation and Palliative Care Services - Case Study Example

Palliation and Palliative Care Services Case Study Palliation and Palliative Care Services Case Study Each and every person of us is glad when he/she has good health system or if someone takes care of him/her when he is suffering from health complications. The aging people are always at risk of suffering from health complications due to their age and the deteriorating immune system. They are prone to terminal diseases and ailments like loss of eyesight, cancer and diabetics conditions, and other health complications. If they are not taken care of they may end up losing their lives or even suffer from more complex health conditions like malfunctioning of some of the body organs. This may further complicate the treatment of the ailing person putting the person at a risk of losing his/her life. Clare is one such person. Clare a 65 year old lady is suffering from lung cancer which is a fatal condition and has being referred to a community palliative care service by her general practitioner. She has been living with her husband Andrew in their family home. Her two grown children are married and live interstate. Clare suffers from breathlessness, cough and fatigue. She gets distressed by her inability to ‘catch her breath’. Sometimes she has trouble sleeping at night and is frequently sleepy during the day. Clare says she doesn’t have many strategies to help her manage her symptoms. She views her illness as a challenge as it impacts on what she can do and she doesn’t feel in control of her life. Andrew, her husband, has being helping her with house chores, shopping and cooking among other activities. People who have ‘come out of the woodwork’ have come to visit Claire at home but she complains of missing her kids a lot despite the fact that she is constant communication with them through phone calls. According to her, personal relationships are more meaningful to her at the moment and she cherishes them a lot. As per the general practitioners advice, Claire is supposed to attend a palliation and palliative care services where she will get the much needed help to improve her health conditions. Though her husband helps her with much of the house and shopping activities, more need to be done to improve her health conditions. This was the reason that necessitated the general practitioner to request her to attend palliation and palliative care services. According to the general practitioner’s view, this will highly improve her health conditions and will make her relax her mind. Her constant loss of sleep at night and feeling sleepy during the day is from the fact that she has no peace in her mind. When she attends palliation and palliative care services center, her health condition will definitely improve (MacLellan, 2006). Palliation and Palliative Care Services Palliative care is a form of medical care concentrating on reducing the severity of any disease or health complications rather than stopping, delaying or reversing progression of the health complications and diseases (Jayarajan, 2007). The main objective and goal is to relieve and prevent suffering in efforts to improve the quality of life for people suffering from serious and complex illnesses. The non hospice palliation in independent of prognosis and is offered in conjunction with the right medical treatment and curative measures (Matzo & Sherman, 2006). Though palliation and palliative care services offers an incredibly broad range of services, the goals are treatment of pain and distressing symptoms, relief from suffering, support of the ailing person to live an active life, spiritual and psychological care and support system for rehabilitating and sustaining the individual’s family (Royal College of Physicians of London, 2008). In most countries, palliative care is mostly given by interdisciplinary teams consisting of various health professionals like registered nurses, physicians, social workers, nursing assistants, physiotherapists, volunteers, complementary therapists and the family. The team’s goals and objectives are to ensure the patient’s comfort. The palliative services are mostly given in acute care hospitals with an interdisciplinary consultation service. The service may be given at the ailing person’s home or long term care facilities. The palliative care centers may also have home health care aids, certified nurse assistants and community volunteers. The most crucial entity in a palliative care system is the caregivers which include volunteers and family. During the course of the care, caregivers and patients form long lasting friendships. As a consequence, the caregivers may suffer from physical and emotional strain. The palliative care system sees the patients through various stages of the disease or health complication containment thereby indicating that the palliative caregivers offer a wide range of services and care to the patients. Such services may range from managing physical symptoms in cancer patients, treatment of depression in patients having advanced illnesses and care of patients in their last hours and days (Esper, Heidrich & Kuebler, 2006). The better percentage of the caregivers’ work is to help patients with severe or complex psychological, physical, spiritual and social problems in ensuring that they sufficiently improve to return home. According to the world health organization, palliative care is the active care of patients suffering from diseases not responsive to medicinal treatments (palliativecare-la.org, 2010). According to Eileen Chrystal-Frances, palliative care of patients suffering from chronically or terminal diseases is a special field of medicinal care slowly emerging in response to changes in the society and mindset in regard to death and dying (ecam.oxfordjournals.org, 2005). The palliative care, according to her, is the interdisciplinary approach emphasizing pain management and social, psychological and spiritual issues. The goal of palliative care is attainment of optimal life quality for the patients involved. The care services comprise of various concepts of management of pain in patients, comfort care and quality of life. Comfort care is linked to the outcomes for instance well being, ease and satisfaction. Palliative care encompasses the hospice philosophy of care striving towards expanding the concept to embrace patients experiencing discomfort or pain but who are not qualified for hospice services. From the definitions given above and the goals and aims of palliative health care services, it is evident that Clare and her family will highly benefit from the services. The cancer symptoms need to be contained and effects reduced to manageable levels for the betterment of the family and Clare. Cancer being as terminal and chronicle disease, then she can not be admitted in a hospice as medication will be of less importance to her. What she requires is psychological and social support which is only available from palliative care center services. The caregivers at the palliative health care facilities will help her accept her situation and will provide the required counseling services. They will particularly inform her of the advantages and disadvantages associated with the various social activities that she might engage in or want to engage in. For instance, the caregivers will inform her how taking long journeys in attempts to reach her children will adversely affect her health. The caregivers will also help the family as a whole to come into reality with Clare’s situation and accept her as she is. The family will be given the necessary guidance and counseling on how they relate with Clare. Through the palliative services, the family will be well informed that Clare might not live for long but deserves better social and psychological treatment to prolong her life. Depression and stress is a big determinant of how long Clare lives and health status. Palliative health care services embrace four ethical principles generally used as the framework for bioethics principles namely beneficence, autonomy, justice and non-maleficence. In palliative health care services and centers, patients are protected form the harm of experiencing pain symptoms and aim at promoting the patient’s welfare by enhancing wellbeing. Clare has been experiencing loss of sleep at night and feels very sleepy during the day, a condition that cannot be treated by use of medicines. This condition is best treated through use of guidance and counseling services after a clear understanding of the causes of the condition. Effective palliative care aims at providing patients with safe ways of addressing their psychological and physical distress commonly referred to as total suffering. Dealing with total suffering is an interdisciplinary field that starts with treating the physical symptoms like breathlessness, pain and nausea. Palliative care teams are skillful in administering drugs to treat the physical symptoms and instrumental in giving ways of safe use of drugs while at the same time maintaining the ailing person’s full function and faculties. Whenever a patient exhibits physiological symptoms, there are also social, psychological and spiritual symptoms as well. The caregivers which comprise of an interdisciplinary team help the patient and family effectively deal with these symptoms instead of depending on the pharmacological and medical intervention alone. Just like in other palliative patients, Clare’s fears and concerns are fears about the future, pain, loss of independence, feeling like a burden to the family and the community, and worries about her family. Though Clare is constantly calls her children, she is not at ease with herself and feels obligated to visit her kids. In dealing with her, the caregivers should not deny her human rights and support system as doing so is like forcing her to deal with issues she does not have or she chooses not to deal with. Palliative health care services maintain quality of life which is paramount to extending life and aims at achieving a balance and wellness on all domains of life. The care services encompass modern and ancient philosophies of care by removing unnecessary human suffering and encouraging kindness. The fact that one is suffering from lung cancer and it’s in its advanced stages is a devastating shock to the family of the patient as well as the patient himself/herself. This fact leads to depression, anger and anxiety as an emotional response. Palliative care comes in handy to offer emotional and physical support in improving the quality of life of the patient as well as the family members. Counseling and guidance of the patient as well as the family members is usually of paramount importance in improving the health of the patient and the psychological condition of the family members. If need be, antidepressant medication may be administered to the patient. The emotional support is very essential in helping the patient and family through thye grieving process. Pain and Pain Management Patients suffering from chronicle and terminal illnesses always suffer from pain which may be mild or chronic. The main side effect of lung cancer is pain especially in the latter stages of its development like stage four. The effective control of pain in the cancer patients is an integral part of the health care services and comprehensive cancer care. Cancer is known for causing pain in 30 percent of patients in the early stages and 85 percent of the patients when the disease is in its advanced stages. The pain either manifesting as headache, stomachache or backache must be contained and managed to reasonable levels (Patterson, 2010). Pain management in the advanced stages of cancer disease is an important aspect of palliative care services. Apart from the physical assessment, care of the family and the patient suffering from chronic and terminal diseases should lay emphasis on social, psychological and spiritual factors. Pain management and assessment is usually done by an interdisciplinary team focusing on comfort and death facilitation that duly respects the life of the dying patient. Pain management involves assessment of pain from the initial stages of the cancer development to the advanced stages. Pain etiology medical evaluation is usually combined with comprehensive and detailed nursing assessment (Benzon, Raj, Rathmell & Wu, 2008). Comprehensive and detailed assessment of such patients starts with selection of adjuvant and opioid analgesics. An interdisciplinary team with an organized approach can attend to patients in pain crisis while at the same time attending to different dimensions of quality of life of the patient and family. Whenever a patient is in pain crisis, the likely pain sources and responses to pain management have to be thoroughly and rapidly assessed. Immediately after assessment, the interdisciplinary caregiver team should start to optimize function and comfort (Waldman & Winnie, 2006). The goals and aims of the health care plan is to find the most effective and simplest co-analgesic and analgesic treatment regimen in efforts to maximize the quality of life of the patient and subsequent quality of life of the family members. Pain management in lung cancer patients and cancer patients in general is best taken care of in palliative health care centers as the disease has very few treatment options. This is especially so when lung cancer has metastasized to the various parts of the body. Palliative health care remains as the only viable option for symptom relief, pain management and emotional support. Pain management may take various forms which include taking painkillers among others (Ballantyne, Fishman & Rathmell, 2009). Apart from the conventional pain medications, chemotherapy and radiotherapy highly relieves pain by shrinking tumors. Not all the pain management practices can work for all the patients. Some of the patients benefits from non traditional approaches while others benefit from relaxation techniques. Pain management remains among the last options of medical control that lung cancer patients have over their lives that have being debilitated by cancer. Pain in cancer patients may emanate from coughing, side effects of lung cancer treatment like mouth sores from chemotherapy and incision pain resulting from a surgical operation, or tumor pressing on the bones, nerves or the pleura. Pain affects the social life of a person by disrupting eating, sleeping and exercise habits consequently leading to depression and stress. When the proper treatment of pain is administered to the patient, then there will be a significant improvement in the way the patient copes when undergoing cancer treatment (Waldman, 2009). Adequate control of pain is physically important and helps in better treatment response like fast healing after a surgical operation. However in managing pain, there are various barriers and hindrances that are encountered. Usually pain in cancer patients is often under treated. There are several factors contributing to this as will be mentioned below. One of the factors is fear of addiction but research show that patients taking medications in controlling cancer pain rarely become addicted. The other factor is the fear that the pain medications will stop working after frequent use therefore leaving the patient with no medication to control pain when it gets worse. But according to medical advice, one can never become immune of pain medicines and there is no reason to fear as there are also many pain relief options available. From the fact that pain medications have side effects, patients fear that they will suffer from side effects and thus complicating the issue. However, it should be noted that there are many painkillers that are fairly easy to control. When the caregivers in the palliative care centers are administering pain killers to the patients, they should put this fact into consideration. It is always advisable to consult professional possessing better information whenever the caregivers are faced with the problem of deciding of the best pain medication to use. As mentioned earlier, palliative services aim at improving the life of the patient. If the wrong medication is used, the goals of palliative services will not have achieved. The other major challenge is financial resources. Cancer pain medications are usually expensive thus making it hard for the patients to afford. However, patients should always feel at ease in the presence of his/her general practitioner or caregiver and express her financial condition so that the practitioner or the caregiver can prescribe a more affordable cancer pain medication. The patient may also be directed to a program where he/she can receive the required financial help. There are mainly three categories of medications for cancer pains namely over the counter medications, opioids and other medications. In over the counter medication, the patient is given over the counter drugs like Advil and Tylenol to help in controlling of mild pain. To control moderate pain, the patients use opioids like codeine and morphine. The other medications require special treatment and includes anti seizure and antidepressants drugs usually used for tingling or burning pain. The patient can also use steroid in controlling pains caused by swellings. Radiotherapy, surgery or chemotherapy can be used in pain medication of the cancer pains emanating from tumors pressing on the bones and the nervous system. Through these methods, the size of the tumor is adequately reduced relieving the patient of the cancer pains. In severe situations, a neurosurgery may be carried out to cut the nerves sending the pain signals to the patient’s brain. The palliative care services may also engage in hypnosis, massage therapy, therapeutic touch and acupuncture. For the best services to be realized, Clare should talk openly to the caregivers and the family at large about the pain she is experiencing. It is obvious that different patients experience pain in different ways and none of the caregivers has the ability to read her mind. It is therefore advisable for Clare to share the levels of pain she is experiencing. She should also share her fears of addiction to medication or that the medication will stop working. She should do so even if she feels that she is burdening her family and caregivers as doing so is the only way to get help from them thus improving her life standards. It is apparent that, she can only get the best medication and care if she lets her condition known to the family as well as to the caregivers (Christo and Mazloomdoost, 2008). Symptom Manifestation and Symptom Management Cancer is known to manifest itself in form of growths and tumors in the various body parts. For one to be able to administer and contain the various forms of cancer, one has to clearly understand how cancer manifests itself and the various symptoms and signs (Vardaxis, 2010). Lung cancer manifests itself through a condition referred to as superior vena cava syndrome. This is a condition whereby the cancerous growth reduces the blood flow through the superior vena cava into the right atrium of the heart. The symptoms of this condition are dyspnea, chest pain, facial swelling and coughing. Through chemotherapy and radiotherapy, these condition’s effects are reduced by reducing the size of the tumor. The condition can further be administered through surgical use of a stent (Fitzgibbon & Loeser, 2010). The surgery aims at expanding the vena cava to allow for blood flow. A stent can be defined as a metallic or plastic tube, covered with a fine mesh, placed inside the blood vessel prompting the normal flow of blood by holding the vena cava open. As stated earlier, dyspnea is one of the symptoms of lung cancer. Dyspnea is the condition that renders one to have difficulty in breathing (Klamerus, Brahmer & Ettinger, 2010). This is one of the symptoms that Clare is suffering from. A tumor in the respiratory airways leads to difficulty in breathing and shortness of breath. It is reported that at least 59% of the stage four victims of cancer report dyspnea (Quant, 2010). To relieve this, radiotherapy and chemotherapy may be employed on the patient. The caregivers can also perform a surgical operation on the patient to remove obstructions in the lungs. The surgeons may use photodynamic therapy to clear away small tumors in the lungs (Goldman, 2005). The caregivers in the palliative care may use oxygen to relieve the patients from the effect of dyspnea. Provision of supplemental oxygen decreases the energy the patient will use in breathing. The caregivers at the palliative care center may give Mrs. Clare supplemental oxygen to suffice her breath intake. In so doing, she will not lose lot of energy as she breaths in and out (Pass, Carbone & Johnson, 2010). Lung cancer is known to cause vocal cord paralysis thus causing changes in voice and hoarseness when one is talking. When the patient is not able to control the vocal cords, he/she may suffer from choking (Sulica & Blitzer, 2006). This condition can be corrected and managed by administering Teflon injection into the vocal cord that is paralyzed providing the vocal cord with extra bulk therefore reducing the chances of choking (Little & Merrill, 2009). A surgical operation may also be done on the patient to help the vocal cords in moving forward thus providing relief from the symptom. The caregivers should be very careful especially with the patients exhibiting vocal cord paralysis as they may suffer death after choking. The caregivers who include her husband, Mr. Andrew and her children should keep close watch over Clare incase she gets a severe choke. When the layers forming the lung membranes are obstructed or inflamed, there is build up of excess fluid in between them. This causes pleural effusion (Light, 2007). The liquid in between the layers builds up pressure causing chest pain, dyspnea and coughing in the patient. To relieve pleural effusion, a needle is inserted into the pleural space in efforts to drain off the excess fluid between the pleural membranes (Parles & Schiller, 2009). Sometimes the caregivers may administer pleurodesis on the patient. In this process a drug is usually injected in the space between the pleural membranes thus sealing the two layers together. This prevents further fluid accumulation thus reducing swelling of the lungs. The palliative health care assistants when they monitor Clare’s condition they may be able to understand the best medication to take whether the use of drugs or minor surgery according to the level of the symptoms. An estimate of 12% of patients in advanced stages of lung cancer is known to be suffering from hypercalcemia. Hypercalcemia is the excessive build up calcium minerals in the patient’s body (Shields, 2009). Hypercalcemia is characterized by nausea, dehydration, mental confusion, kidney stones and subsequent coma and death if left untreated. The condition is usually common in elderly people and the rate of malignancy increases with age (Heber, 2006). To relieve the patient, administration of intravenous hydration and diuretic is often beneficial. Hypercalcemia may cause the patient to vomit, alter the mental status, have abdominal or flank pain, constipate, lethargy, depression, be weak and have vague muscle or joint aches, have mild or severe headache and may cause confusion. When the calcium levels increase to unreasonable levels, the patients may go into a coma (Old, & Swagerty, 2007). A moderate elevation of the calcium levels is likely to cause symptomatic especially in elderly patients. Hypercalcemia is known to cause hypertension and bradycardia in patients and the possibility of stomach ulcers. Tongue fasciculations and hyper reflexia may also manifest in a patient suffering from hypercalcemia (Escalante, Gagel & Yeung, 2009). A long standing hypercalcemia is known to cause band keratopathy. The condition is mainly treated through increasing the salt intake of the patient, hydration and forced diuresis. Hydration is always necessary as many patients suffer dehydration as a result of renal defects in concentrating urine and vomiting. Increasing the salt intake to the patients will surely increase the volume of the body fluid and urine sodium excretion (Payne, Seymour & Ingleton, 2008). This consequently increases calcium excretion in the urine form. However, the caregivers should always take the necessary precautions to prevent magnesium and potassium depletion. The caregivers can also administer calcitonin and bisphosphonates possessing a high affinity for bone. Patients with cancer associated hypercalcemia like Clare should receive bisphosponates treatment as their use is both preventative and therapeutic. However, risk benefit analysis should be carried on patients with hypercalcemia and renal failure before bisphosphonates is administered to them. Calcitonin inhibits renal calcium re-absorption thus increasing urinary calcium excretion and blocks bone resorption. The use of calcitonin is accompanied with diuresis, bisphosphonates and rehydration. The use of calcitonin helps in prevention of recurrence of hyprecalcemia (Zerwekh, 2006). The above mentioned methods are not the only ones that can be used in controlling hypercalcemia. There are other methods like plicamycin, dialysis, glucocorticoids and phosphate use. A person suffering from lung cancer may also exhibit hemoptysis, coughing of blood especially from the lungs. Hemoptysis is the expectoration of blood or blood stained sputum mainly from the lungs, trachea, bronchi and larynx. The condition can be cured by administering topical vasoconstrictors like vasopressin or adrenalin, or iced saline. If there is hemorrhage in the lungs, then selective bronchial intubation is used to collapse the lungs (Haas, 2010). Use of endobranchial tamponade can also be administered to the patient. Laser photocoagulation is often used to stop bleeding especially during bronchoscopy. In locating the source of the bleeding, angiography of the bronchial arteries is usually performed on the patient. As a last option, a surgical operation may be done on the patient to rectify the bleeding problem. The surgical operation may involve pneumonectomy or lobectomy. Radiotherapy can be carried out on the patient to lessen hemoptysis whereas photodynamic prevents bleeding (Fauci & Longo, 2010). Self Care and Issues in Palliative Care Nursing Practice Although palliative health care is concerned with taking care of the patient, there is need for the patient to take good care of himself/herself. No matter the efforts by the caregivers, the paramount efforts emanate from the patient herself. Mrs. Clare should adhere to the instructions of the general practitioner and the caregivers and should cooperate with them to ensure that she improves her health status (Matzo & Sherman, 2006). She should accept her condition and try as much as possible to deviate from undertaking activities that will stress her body mechanism. Such activities may cause depression thus deteriorating her health status. This may shorten her life on earth thus not meeting the goals and aims of a palliative health care system (Byrne, McNamara & Seymour, 2009). It should be noted that for the best results in a palliative health care system, all the parties involved should be actively involved in improving the life of the patient. Conclusion Palliative care has helped lengthen the lifespan of the patients as well as helped the family of the patient to better understand the patient. Through best palliative health care, the symptoms Clare is suffering from will be able to be controlled and contained therefore improving her health immensely. The psychological support given to her by the palliative health care assistants will help her as well as the family understand her condition and realize that death is inevitable. Through palliative health care Andrew, Clare’s husband, will learn how to take good care of is wife and thus feel is of importance to his wife. The healing hand impacts, opportunity to provide guidance and support, and willingness to listen will greatly improve the health condition of Clare and will also help the family at large to be psychologically prepared. References Ballantyne J. C., Fishman S.M. & Rathmell J. P. (2009), Bonicas management of Pain, New York, Lippincott Williams & Wilkins. Benzon H.T., Raj P. P., Rathmell J.P. & Wu C. L., (2008). Rajs practical management of pain, St. Louis, Mosby-Elsevier. Blitzer A., Sulica L. (2006), Vocal cord analysis, Boston, Birkhäuser. Byrne J, McNamara P. & Seymour J. (2009), Palliative care in neurological disease: a team approach, Abingdon, Radcliffe Publishing. Carbone D. P., Johnson D. H. & Pass H. I. (2010), Principles and Practice of Lung Cancer (4th edition), London, Lippincott Williams & Wilkins. Christo, P. and Mazloomdoost D. (2008), Interventional pain treatments for cancer pain, New York, Academy of Sciences. Ecam.oxfordjournals.org (2010), Defining palliative health care, retrieved on 31st August 2010, http://ecam.oxfordjournals.org/cgi/content/full/2/2/227. Escalante C. P., Gagel R. F., Yeung S. J. (2009), medical care of cancer patients (illustrated), New York, PMPH-USA. Esper P., Heidrich D. E. & Kuebler K. K. (2006), Palliative & End-Of-Life Care: Clinical Practice Guidelines, Amsterdam, Elsevier Health Sciences. Fauci A. S., Longo D. L (2010), Harrisons Gastroenterology and Hepatology, New York, McGraw Hill Professional. Fitzgibbon D. R, Loeser J. D. (2010), Cancer Pain: Assessment, Diagnosis, and Management, New York, Lippincott Williams & Wilkins. Goldman M. P. (2005), photodynamic therapy, Amsterdam, Elsevier Saunders. Haas M. (2010), Contemporary Issues in Lung Cancer: A Nursing Perspective (2nd edition), London, Jones & Bartlett Learning. Heber D. (2006), Nutritional Oncology, London, Academic Press. Jayarajan N. (2007), Palliation, Portland, Reed College. Klamerus J. F., Brahmer J. R. & Ettinger D. S. (2010), Johns Hopkins Patients Guide to Lung Cancer, London, Jones & Bartlett Learning. Light W. R. (2007), Pleural diseases, New York, Lippincott Williams & Wilkins. Little A. G. & Merill W. H. (2009), Complications in Cardiothoracic Surgery: Avoidance and Treatment (2nd edition), London, John Willey and Sons. MacLellan, K. (2006). Expanding nursing and healthcare practice - Management of pain: A practical approach for healthcare professionals. Cheltenham: Nelson Thornes. Matzo M., Sherman D. W. (2006), Palliative care nursing: quality care to the end of life, Florence, Springer Publishing Company. Old, J. L., & Swagerty, D. L. (2007). A practical guide to palliative care. Philadelphia, PA: Lippincott Williams & Wilkins. Palliativecare-la.org (2010), Palliative care and palliative medicine, retrieved on 31st August 2010, http://www.palliativecare-la.org/. Parles K. & Schiller J. H. (2009), 100 Questions & Answers About Lung Cancer (2nd edition), Sudbury, Jones & Bartlett Learning. Patterson D. R., (2010), Clinical Hypnosis for Pain Control, Washington D.C., American Psychological Association. Payne, S., Seymour, J., & Ingleton, C. (Eds.). (2008). Palliative care nursing: Principles and evidence for practice. (2nd ed.). New York: Open University Press. Quant E. (2010), Dx/ Rx Brain Tumors (revised edition), London, Jones & Bartlett Learning. Royal College of Physicians of London (2008), Palliative care services: meeting the needs of patients: report of a working party, London,Royal College of Physicians. Shields T. W. (2009), General thoracic cavity (7th edition), New York, Lippincott Williams & Wilkins Vardaxis N. (2010), A Textbook of Pathology (2nd edition), Australia, Elsevier. Waldman S. D. & Winnie A. P., (2006), Interventional pain management, Philadelphia, W.B. Saunders Co. Waldman S. D., (2009). Atlas of interventional pain management, Philadelphia, Elsevier Health Sciences. Zerwekh, J. V. (2006). Nursing care at the end of life: Palliative care for patients and families. Philadelphia, PA: F.A Davis Company. Read More